Working with individuals with addiction problems is challenging. Part of the challenge is to balance multiple theories and ideas. In talking with a client for the first time, or the hundred and first time, I have to be thinking Stage of Change (SOC) – where is this person in relationship to this problem? Are they precontemplative? Are they in a preparation stage? Are they in an action stage with regards to their use of cocaine but precontemplative when it comes to tobacco?
SOC is a model that all clinicians need to understand. It allows us to identify where a client is at, but it can become like bird watching – “there’s a white-throated sparrow”. It’s a one way process.
Motivational Interviewing takes it a step beyond; it teaches that SOC is one part of the equation but what’s going on in the conversation between client and clinician can itself be a factor in how things unfold. It’s not that we are just birdwatchers/diagnosticians, we are more like dancers, inviting the person to join us on the dance floor. And like a couple dancing, one person’s dance steps has an effect on the others.
I recently picked up a book on Substance Abuse Treatment and SOC. The authors write that
“Persons in the precontemplation stage generally are unaware or ignorant of their drug use problem. If aware, they are not thinking seriously about their drug use or about making changes in it.”
“Denial has been described as a core strategy used by substance abusers to deal with life and to avoid awareness of their substance use problems.”
It’s not that I don’t believe substance abusers use denial – I think pretty much everyone (including me) uses it at times. But I keep coming back to the issue of ambivalence.
William L. White, reflecting on his career working in addictions writes:
“The history of addiction as experienced by America’s addicts is a history of ambivalence. Addicts simultaneously want – more than anything – both to maintain an uninterrupted relationship with their drug of choice and to break free of the drug” …
That’s it! I’ve met patients/clients where initially they appear in complete denial but as we talk, as the person becomes more comfortable to discuss things that often trigger a judgmental response, their ambivalence starts to come out.
Ambivalence! Grasp this concept and it will help you understand so much more than just using the construct of Denial. Plus it will make you a better dancer partner!
Consider checking out the Prezi I put together with a series of quotes from White’s book Slaying the Dragon.
Shalom Coodin MD FRCPC
1 June 2016